OB Theory Intrapartum_Ch_13,14,21-2 PDF

“ He who works with his hands is a laborer. He who works with his hands and his head is a craftsman. He who...

“ He who works with his hands is a laborer. He who works with his hands and his head is a craftsman. He who works with his hands D R. G I N A W I L D I N G and his head and his heart is an artist.” Saint Francis of Assisi NUR252 OB T H E O RY I N T R A PA RT U M The Art of Nursing  W E LC O M E TO I N T R A PA RT U M  Progesterone drops. Oxytocin starts. babys start prostoglandins. uterine stretch caused by big babies, polyhydraminos, multiple gestation. W H AT CAUSES L A B O R TO S TA RT ? W H AT C A U S E S L A B O R TO S TA RT ? Changes within the myometrium, decidua, and cervix Gradually over days or weeks Theories Uterine stretch: fetus and amniotic fluid volume Progesterone withdrawal to estrogen dominance Increased oxytocin sensitivity Increased receptor sites Increased release of prostaglandins Fetal cortisol synthesize prostaglandins All occur to make contractions, cervical softening, gap junction induction and myometrial sensitization cervix starts to soften which allows it to open and thin. cervival ripening is cervix starting to soften and thin. I F U T E R I N E S T R E TC H I S A T R I G G E R F O R L A B O R TO B E G I N , W H AT C O N D I T I O N S W O U L D B E A R I S K FA C T O R F O R P R E T E R M LABOR? Short stature or short waist also P R E M O N I T O RY S I G N S O F L A B O R Cervical Changes Increased Energy Lightening Softening and possible Level Fetus descends into true dilation (1month to 1 hr 24 – 48 hours prior to pelvis prior) labor, “nesting” Braxton Hicks Spontaneous Rupture Bloody Show Contractions of Membranes Mucus plug Last 30 sec to 2 min, Prelabor rupture of tightening to abdomen membranes (PROM) happens before labor starts  T R U E V S FA L S E L A B O R True Labor False Labor Timing Regular, usually 4-6 min Timing Irregular, not close apart, lasting 30 – 60 together sec, becoming closer Strength Weak, not getting Strength Stronger with time, stronger or not feeling vaginal pressure consistently stronger Discomfort Starts in back and Discomfort Felt in the front of the radiates to front of abdomen abdomen Change in Activity May slow or stop with Change in Activity Position changes do not position change or walking stop contractions Stay or Go Drink fluids, walk around, Stay or Go Go: difficult to talk position change, if no through ctx. Every 5 increase or weakened: min, lasting 45-60 sec Stay home  Passageway – birth canal Passenger – fetus and placenta 5 FA C TO R S AFFECTING THE LABOR Powers – contractions P RO C E S S Position – maternal Psychological response L A B O R DY S TO C I A Abnormal progression of labor 10% of all labors Leading indicator for primary cesarean section – “failure to progress” Lack of cervical change and/ or lack of descent Problems with the 5 Ps of labor and delivery P A S S A G E W AY – 3 P A R T S O F T H E B O N Y P E LV I S Is the following statement true or false? The true pelvis lies below the linea terminalis. a. True b. False a. True The true pelvis lies below the linea terminalis. The false pelvis lies above the linea terminalis. P E LV I C S H A P E S Gynecoid: True female pelvis: 40% of all females (most favorable for vaginal birth) Anthropoid: Common in men, non-white females: 25% of all females (more likely to have vaginal birth) Android: male pelvis: 20% of all females (fetal descent is slow, likely C/S) Platypelloid: 3 % of females, not common (likely C/S)  S O F T T I S S U E – C E R V I X , P E LV I C F LO O R , A N D VA G I N A pelvis floor too tight- difficult to descend pelvic floor too loose- baby wont tuck chin to chest. P R O B L E M S W I T H P A S S A G E W AY Pelvis shape Android and Platypelloid Short A-P diameter Contractures within the pelvis inlet or outlet Obstruction of birth canal Placenta previa Fibroids Swollen cervix HPV warts Full bladder and/or rectum NURSING A SSESSMENT/MANAGEMENT Assess labor Progression (slow), contractions (poor), and dilation (slow) Possible prep for forceps, vacuum, cesarean section Evaluate bowel and bladder – soft tissue obstruction Trial of labor – assess for adequate trial and proceed of prep for cesarean birth PA S S E N G E R - F E TA L S K U L L MOLDING Biparietal diameter: largest diameter F E TA L AT T I T U D E AND LIE Full Flexion F E TA L C E P H A L I C P O S I T I O N A. Vertex B. Military C. Brow D. Face F E TA L B R E E C H A. Frank B. Complete C. Single footling D. Double P R E S E N TAT I O N footling Is the following statement true or false? Cephalic presentation refers to a fetus whose head enters the pelvic inlet first. a. True b. False a. True When the head of the fetus is the first part of the fetus to enter the pelvic inlet, the fetus is said to be in the cephalic presentation.  F E TA L ENGAGEMENT AND DESCENT  F E TA L POSITION 1st Letter: Presenting part tilting left or right 2nd Letter: Presenting part O=occiput/S=sacrum/M=mentum 3rd Letter: Presenting part in relation to the pelvis A=anterior/P=posterior/T=transverse  CARDINAL MOVEMENTS Positional changes of the passenger through the passageway P RO B L E M S W I T H PA S S E N G E R Fetal Presentation Persistent occiput posterior Face or brow presentation Breech presentation Shoulder Dystocia Multiple Pregnancy Fetal size or abnormalities Macrosomia NURSING A SSESSMENT/MANAGEMENT Assess labor Progression (slow), contractions (poor), and dilation (slow) Possible prep for forceps, vacuum, cesarean section Identify risk factors Provide labor support, promoting rotation Assess for fetopelvic disproportion Explain fetal malposition and management (external version) Evaluate fetal monitor for signs of fetal hypoxia SHOULDER DY S TO C I A  Review client history Identify risk factors: maternal short stature, obesity, hydramnios, uterine abnormalities, fetal malpresentation, cephalopelvic disproportion, overstimulation with oxytocin, maternal exhaustion, ineffective pushing, excessive size fetus, poor maternal pushing efforts, maternal fear and anxiety Assess maternal frame of mind Assess VS, contractions, FHR patterns, fetal position NURSE ASSESSMENT  Promoting labor progress Evaluate progress and fetal well being Administer oxytocin Providing physical and emotional comfort Reduce environmental stimulation Provide physical comfort, frequent position changes Promote empowerment Educate client and family about dystocia, interventions. Allow expression of feelings Support non-traditional families NURSE MANAGEMENT  POWER – UTERINE CONTRACTIONS/ INTRA - ABDOMINAL PRESSURE P RO B L E M S W I T H P OW E R S Uterine Dysfunction – no or limited labor progress Hypertonic – Latent phase Hypotonic - secondary (labor begins normally) Precipitate Labor Less than 3 hours from start of contractions to birth Maternal risks Cervical lacerations, uterine rupture Fetal risks Head trauma, hypoxia NURSING A SSESSMENT/MANAGEMENT Administer medications Therapeutic rest - hypertonic Oxytocin – hypotonic Tocolytics – slow labor Evaluation fetal monitor for signs of hypoxia Prepare for augmentation – SROM, oxytocin Prepare for quick labor and birth – possible planned induction Educate on dysfunctional pattern  Benefits of the upright positions Reduce length of first stage Reduce duration of second stage Reduce assisted deliveries Reduce episiotomies and lacerations Fewer abnormal FHR patterns M AT E R N A L Reduce requests for pain meds POSITION Enhanced sense of control by client Assist with descent (alters pelvic shape) Gravity assists fetal descent W H AT A R E S O M E P R O B L E M S WITH POSITION? W H AT I S T H E N U R S I N G A SSESSMENT/MANAGEMENT?  Life altering experiences: Positive Factors Clear information about procedures Support, not alone PSYCHOLOGICAL Self confidence RESPONSE Trust in staff Positive reaction to pregnancy Personal control over breathing Preparation for childbirth experience P RO B L E M S W I T H P S YC H E - Physiology: stress hormone release – not therapeutic Reduces smooth Decreases Increases poor muscle contractility uteroplacental newborn of the uterus perfusion adjustment NURSING A SSESSMENT/MANAGEMENT Establish safe environment Therapeutic relationship Be present and open Include support person (people) Determine source of fear, anxiety, stress and address Lack of knowledge (inform/update frequently) Previous experience from pregnancy, birth, or sexual trauma etc (ensure client control of body and decisions) Pain (provide options for pain management or administer pain medication)  5 A D D I T I O N A L FA C TO R S Philosophy – low-tech, high-tech Partner – support caregivers Patience – natural timing Patient – (client) preparation (childbirth knowledge base) Pain management – comfort measures  First Stage - Labor Latent Phase: 0 – 6 cm Active Phase: 6 – 10 cm S TA G E S O F LABOR Second Stage - Birth Third Stage - Placenta Fourth Stage – Recovery (1-4h) 2 P H A S E S O F T H E F I R S T S TA G E Latent Phase Active Phase Cervical dilation: 0-6cm Cervical dilation: 6-10cm Cervical effacement: 0-40% Cervical effacement: 40-100% Contraction frequency: every 5-10min Contraction frequency: every 2-5min Contraction duration 30 – 45 seconds Contraction duration 45-60 seconds Contraction Intensity: mild palpation Contraction Intensity: moderate palpation Lasts: Lasts: Nullipara: Up to 20 hours Nullipara: Up to 6 hours Multipara: Up to 14 hours Multipara: Up to 4 hours 2 P H A S E S O F S E C O N D S TA G E Pelvic Phase Perineal Phase Period of fetal descent Period of active pushing Laboring down Contraction frequency: every 2-3min Use of peanut ball Contraction duration 60-90 seconds Use of position changes Contraction Intensity: strong palpation Babe can be born without coached maternal Strong urge to push during later part of phase pushing Lasts: Nullipara: Up to 3 hours Multipara: Up to 2hours B A L LO O N V I D E O A N D AC T I V I T Y https://www.youtube.com/watch?v=URyEZusnjBI  S I G N S O F P L A C E N TA L S E PA R AT I O N Upward rise of the placenta Umbilical cord lengthens Trickle of blood seen at vaginal opening Uterus changes to globular shape Is the following statement true or false? The second stage of labor is the longest stage. a. True b. False b. False The first stage of labor is the longest stage. F E TA L H E A R T M O N I T O R I N G I N D U C T I O N O R A U G M E N TAT I O N OF LABOR https://www.babycenter.com/pregnancy/your-body/live-birth-induction_10300051 HOW DOES INDUCTION MIMIC T H E N AT U R A L P R O C E S S ? Unchangeable Changeable Can we change uterine stretch (fetal size Can we increase prostaglandins? and amniotic fluid)? Can we increase oxytocin sensitivity? Can we decrease the progesterone and increase the estrogen level? Can we increase the fetal cortisol level?  I N D U C T I O N / A U G M E N TAT I O N Induction: Stimulation of contractions via medical or surgical means prior to the onset of labor Augmentation: Enhances ineffective contractions after the start of labor Indicated when benefits of birth outweigh the risks to the fetus or mother for continuing the pregnancy  INDUCTION Cascade of Interventions All-time high in US Intravenous therapy Increases the risk of C/S Bed rest Increased time in labor and birth Continuous electronic fetal monitoring Pain from stimulating uterine Increased instrumented delivery contractions Increased use of epidural analgesia Epidural analgesia or anesthesia Increase neonatal intensive care unit Prolonged stay admissions  W H O R E C O M M E N D AT I O N S ( 2 0 1 8 ) 01 02 03 04 05 06 Perform for clear Do not leave induced Use of oxytocin for Rule our Do not induce with Monitor contractions medical indications women alone delay in labor with an cephalopelvic abnormal fetal and fetal heart epidural not disproportion has presentations monitoring closely recommended been ruled out before induction  Reasons for Induction Contraindications for Induction Complete placenta previa Placental abruption Prolonged Gestational gestation – most PPROM Transverse fetal lie hypertension common Prolapsed cord Prior classic uterine incision Cardiac disease Chorioamnionitis Dystocia Pelvic structure abnormality Previous myomectomy Vaginal bleeding of unknown cause Intrauterine feal Isoimmunization Diabetes Invasive cervical cancer demise Active genital herpes infection Abnormal fetal heart rate patterns  NURSE ASSESSMENT AND MANAGEMENT Assess: Gather history and perform PE Monitor VS, FHR, contractions pattern and strength Validate EDB: prevent PTB Administer induction means Determine Bishop Score Monitor maternal and fetal response Helps to determine probability of induction success Types: Educate: r/t risks/benefits of induction and not Medication inducing Ripening – Cervidil, misoprostol Contractions - Oxytocin Education: induction process, medication, pain management Mechanical (balloon, laminaria) Surgical (stripping, AROM) Types: Medication (ripening, contractions), mechanical Administer pain medication Provider alternative methods of comfort  BISHOP SCORE S C O R E < 6 I N D I C AT E S C E RV I C A L R I P E N I N G N E E D E D Score Dilation (cm) Effacement Station Cervical Position of (%) Consistency Cervix 0 Closed 0-30 -3 Firm Posterior 1 1-2 40-50 -2 Medium Midposition 2 3-4 60-70 -1 or 0 Soft Anterior 3 5-6 80 +1 or +2 P R A C T I C E YO U R B I S H O P S C O R E SKILLS What is the bishop score of this client A? 3/30%/-2, Medium, Mid-position What is the bishop score of this client B? 5/70%/0, soft, Anterior What is the bishop score of this client C? Closed/10%/-3, Firm, Posterior Which client is most likely to achieve a successful vaginal birth?  ANSWERS Client Dilation (cm) Effacement Station Cervical Position of Total Score (%) Consistency Cervix Client A 2 0 1 1 1 5 (3/30%/- 2,med,mid) Client B 3 2 2 2 2 11 (5/70%/0,soft, ant) Client C 0 0 0 0 0 0 (cl/10%/- 3,firm,post)  Adverse reaction Uterine hyperstimulation Fetal compromise Impaired oxygenation OX Y TO C I N Side effects PRODUCED IN POSTERIOR Antidiuretic P I T U I TA RY N AT U R A L LY Decreased urine flow S H O RT HALF-LIFE(1 TO 5 Water intoxication MIN) Nausea and headache Hypotension  Piggybacked into main IV line at most proximal port to insertion site. Commonly 10 units of Oxytocin are added to 1000ml of Lactated Ringer (isotonic solution) NURSE MANAGEMENT Follow facility protocol for titration (dosage, infusion rates, and frequency change) O F OX Y TO C I N Establish stable contractions every 2 – 3 minutes lasting 40 – 60 seconds Note resting tone between contractions (needs to decrease below 20 mm Hg) Monitor Fetal heart tracing for non reassuring patterns The labor and delivery nurse is administering oxytocin for the purpose of an induction of labor. The nurse notes the fetal heart tracing: baseline is 145, moderate variability, accelerations are present, no decelerations. The nurse notes this is a category 1 strip. The contractions are occurring every 7 minutes, lasting 30 seconds for the past 30 minutes. What is this nurse’s next nursing action? Why?  Vaginal Examination Assessing Uterine Contractions M AT E R N A L A N D F E TA L Amniotic Fluid Evaluation ASSESSMENT/ MANAGEMENT Evaluation of Fetal Heart Rate Labor Support Risk assessment Preparation, communication VAG I N A L E X A M Subjective Judgement (palpation): Mild (nose) Moderate (chin) Strong (forehead) ASSESSING UTERINE CONTRACTIONS Electronic Monitoring: External or internal ASSESSING UTERINE CONTRACTIONS D E T E R M I N I N G T H E P R E S E N TAT I O N , POSITION, LIE: LEOPOLD MANEUVERS  A M N I O T I C F L U I D : A N A LY S I S Spontaneous vs Artificial Infection: cloudy or foul odor Color: Green (meconium)  Non-Pharmacologic Pharmacologic Systemic Analgesia: PO, IM, IV Continuous Labor Support Opioids Hydrotherapy Antiemetics Ambulation and Position Changes Benzodiazepines Acupuncture and Acupressure Nitrous Oxide (inhaled) Position Changes Regional Heat and Cold Epidural Imagery Combined spinal – epidural Effleurage (light stroking) and Massage Local infiltration Breathing Techniques Pudendal block Intrathecal (Spinal) General L A B O R S U P P O RT PRETERM Regular contractions with cervical change prior to LABOR the end of 37th week of gestation (20w -36w6d) PRETERM LABOR One in ten infants born premature in US and increasing One of most common obstetric complications African Americans experience twice the rate as other demographics $820 million spent annually  Risk prediction Helpful if therapeutic intervention available Tocolytic Therapy THERAPEUTIC Prolong pregnancy 2-7 days (help obtain steroid window) MANAGEMENT Corticosteroids Reduce Respiratory Distress Syndrome Prophylaxis antibiotics If indicated for GBS, birth imminent W H AT I S T H E P U R P O S E O F U S I N G INDOMETHACIN WITH PRETERM LABOR? W H AT C A U S E S L A B O R TO S TA RT ? Changes within the myometrium, decidua, and cervix Gradually over days or weeks Theories Uterine stretch: fetus and amniotic fluid volume Progesterone withdrawal to estrogen dominance Increased oxytocin sensitivity Increased receptor sites Increased release of prostaglandins Fetal cortisol synthesize prostaglandins All occur to make contractions, cervical softening, gap junction induction and myometrial sensitization M E D I C AT I O N S Magnesium Sulfate – relax uterine muscle Indomethacin (Indocin) – NSAID, anti-prostaglandin Procardia (Nifedipine) – Decrease uterine activity Betamethasone – Fetal lung maturity NURSING ASSESSMENT Identify Risk Factors NURSING ASSESSMENT Inquire about preterm labor Client may not be aware of signs symptoms Change in vaginal mucus General sense of discomfort Pelvic pressure or fullness Heaviness or aching in thighs Low, dull backache Uterine contractions with or Menstrual-like symptoms without pain UTI symptoms More than six contractions per hour GI upset, N/V, diarrhea Intestinal cramping with or without diarrhea  NURSING ASSESSMENT Assess contractions, cervical effacement and dilation Persistent Contractions: 4 contractions in 20 minutes Cervical effacement: >80% Dilation: >1 cm Assess Labs UA, CBC, AF analysis: lung maturity/infection (chorioamnionitis) Fetal fibronectin Glycoprotein produced by the chorion if labor is going to happen in 1-3 weeks. Normally absent between 24 and 34 weeks Negative test strong predictor of no labor in 2 weeks Assess cervical length Transvaginal US: length of 3 cm delivery within 14 days unlikely Administer tocolytics Provide education Psychological support NURSE MANAG EME N T POSTTERM LABOR – PREGNANCY L A S T S LO N G E R T H A N 4 2 W E E KS Occurs in 10% of pregnancies Assess: EDB, encourage FKC, Usually caused by incorrect dates Perform Non-stress test twice weekly Unknown etiology AFI Maternal Complication Risks Cervical exams weekly Cesarean birth, dystocia, birth trauma, Educate client and family: expectant postpartum hemorrhage, and infection management vs induction Fetal Complication Risks Psychosocial support Macrosomia, shoulder dystocia, brachial plexus injuries, low APGAR scores, post- Provide intrapartum care maturity syndrome, cephalopelvic disproportion  TO L AC / V B AC TOLAC: Trial of labor after cesarean VBAC: Vaginal birth after cesarean Contraindications: Previous classical incision on the uterus, myomectomy or other uterine scar than low transverse Macrosomia, contracted pelvis, Gestational diabetes, Over 40 years old, obesity, short maternal stature Inadequate staff in an emergency Risk for uterine rupture Consent, Documentation, Surveillance, Readiness  UTERINE RUPTURE Rare OB emergency with high maternal and fetal morbidity Tearing of the uterus: marked with abdominal pain, fetal bradycardia, loss of station, vaginal bleeding Assess for risk factors: Previous uterine surgery Assess to FHR changes of distress Prepare for immediate cesarean birth to save mom and fetus Monitor VS and s/s of hypovolemic shock Speed of Obstetric emergency Sudden onset of hypotension, hypoxia, and coagulopathy due to breakage in barrier between maternal circulation and amniotic fluid Nursing assessment: difficulty breathing, hypotension, cyanosis, seizures, tachycardia, coagulation failure, DIC, pulmonary edema, uterine atony with subsequent hemorrhage, ARDS, cardiac arrest Nursing management: supportive measures to maintain oxygenation and hemodynamic function and to correct coagulopathy; critical care monitoring Surgical rescue determine outcome A M N I OT I C F L U I D E M B O L I S M – A N A P H Y L AC TO I D S Y N D RO M E O F PREGNANCY Obstetric emergency: 1 in 40,000 births. ~50% women die in first hour. Mix of amniotic fluid into maternal circulation Sudden onset of hypotension, hypoxia, and coagulopathy due to breakage in barrier between maternal circulation and amniotic fluid Nursing assessment: difficulty breathing, hypotension, cyanosis, seizures, tachycardia, coagulation failure, DIC, pulmonary edema, uterine atony with subsequent hemorrhage, ARDS, cardiac arrest Nursing management: supportive measures to maintain oxygenation and hemodynamic function and to correct coagulopathy; critical care monitoring I N T R A U T E R I N E F E TA L D E M I S E Many different causes, but many time unknown Occurs between 20weeks and prior to birth Devastating to mother and family, associated with PTSD Also affects staff Use appropriate care for families, sensitive to loss Assist with grieving Referrals to social work and chaplain SHARE, pregnancy and infant loss support No FHT, confirm with US. Induction, pain management early  P RO C E D U R E S O F L A B O R ( I N T E RV E N T I O N S ) H T T P S : / / W W W. O S M O S I S. O R G / L E A R N / B I R T H - R E L A T E D _ P R O C E D U R E S : _ N U R S I N G ? F R O M = / R N / N U R S I N G - C O U R S E S / M A T E R N A L - N E W B O R N - N U R S I N G / I N T R A P A R T U M / N U R S I N G - A C R O S S - T H E - L I F E S P A N F O RC E P S OR VA C U U M ASSISTED B I RT H The labor and delivery nurse is administering oxytocin for the purpose of an induction of labor. The nurse notes the fetal heart tracing: baseline is 145, minimal variability, no accelerations are present. There is currently a prolonged deceleration with a nadir of 55. This is the second prolonged deceleration in the last 10 minutes. The nurse notes this is a category ___ strip. The contractions are occurring every 1.5 minutes, lasting 60 seconds for the past 30 minutes. The nurse notes this contraction pattern as ___________________________. What is this nurse’s next nursing action? Why? C E S A R E A N S E C T I O N B I RT H